Original Research
Chlorhexidine-Alcohol Compared With
Povidone-Iodine for Preoperative Topical
Antisepsis for Abdominal Hysterectomy
Shitanshu Uppal, MBBS, Ali Bazzi, MD, R. Kevin Reynolds, MD, John Harris, MD, MSc,
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Mark D. Pearlman, MD, Darrell A. Campbell, MD, and Daniel M. Morgan, MD
OBJECTIVE: To compare preoperative chlorhexidine-
alcohol topical antiseptic agent with povidone-iodine in
patients undergoing abdominal hysterectomy for benign
indications.
METHODS: A retrospective cohort study of patients
undergoing abdominal hysterectomy from July 2012 to
February 2015 in the Michigan Surgical Quality Collab-
orative was performed. The primary exposure was the
use of chlorhexidine-alcohol or povidone-iodine. The
primary outcome was surgical site infection within 30
days. Multivariable logistic regression and propensity
score matching analysis were done to estimate the
independent association of skin antiseptic choice on
the rate of surgical site infection.
RESULTS: Of the total 4,259 abdominal hysterectomies
included, chlorhexidine-alcohol was used in 70.5%
(n53,005) and povidone-iodine in 29.5% (n51,254) of
surgeries. The overall unadjusted rate of any surgical site
infection was 2.9% (95% CI 2.5–3.5; n5124). The
unadjusted rate of surgical site infection 2.6% (95% CI
From the Departments of Obstetrics & Gynecology and Surgery and the Institute
of Healthcare Policy and Innovation, University of Michigan, Ann Arbor, and the
Department of Obstetrics and Gynecology, St. John Hospital and Medical Center,
Detroit, Michigan.
Presented as an oral plenary during the Society of Gynecologic Surgeons’ 42nd
annual meeting, April 10–13, 2016, Palm Desert, California.
The authors thank Dr. Karen McLean and the Michigan Gynecologic Oncology
Workgroup for their feedback on this project and Sarah Block for her editorial
assistance.
Each author has indicated that he or she has met the journal’s requirements for
authorship.
Corresponding author: Shitanshu Uppal, MBBS, Department of Obstetrics and
Gynecology, Division of Gynecologic Oncology, University of Michigan, 1500
East Medical Center Drive, Ann Arbor, MI 48109; email: uppal@med.umich.
edu
Financial Disclosure
The authors did not report any potential conflicts of interest.
© 2017 by The American College of Obstetricians and Gynecologists. Published
by Wolters Kluwer Health, Inc. All rights reserved.
ISSN: 0029-7844/17
VOL. 130, NO. 2, AUGUST 2017
Copyright ª by The American College of Obstetricians
and Gynecologists. Published by Wolters Kluwer Health, Inc.
Unauthorized reproduction of this article is prohibited.
2.1–3.3; n579) for chlorhexidine-alcohol and 3.6% (95%
CI 2.7–4.8; n545; P5.09) for the povidone-iodine group.
Using multivariate logistic regression and adjusting for
differences between populations in patient demographic
factors (age and body mass index), medical comorbid-
ities (American Society of Anesthesiologists class and
diabetes status), perioperative variables (estimated blood
loss, surgical time, intraoperative adhesions, and
antibiotic categories), and hospital characteristics (bed
size and teaching status), we estimate that patients
receiving chlorhexidine-alcohol had 44% lower odds
of developing a surgical site infection (adjusted odds
ratio 0.56, 95% CI 0.37–0.85, P5.01). Propensity score
matching (one to one) yielded 808 patients in the
chlorhexidine-alcohol group and 845 patients in the
povidone-iodine group. In the matched groups, the rate
of surgical site infection was 1.5% (95% CI 0.8–2.6; n512)
for the chlorhexidine-alcohol group and 4.7% (95% CI
3.5–6.4; n540) for the povidone-iodine group (P,.001).
CONCLUSION: In abdominal hysterectomy performed
for benign indications, chlorhexidine-alcohol-based skin
antisepsis is associated with overall lower odds of
surgical site infection compared with povidone-iodine.
(Obstet Gynecol 2017;130:319–27)
DOI: 10.1097/AOG.0000000000002130
S
urgical site infections have been linked to longer
hospital stays, higher readmission rates, and
increased health care costs.1–3 Approximately
200,000 hysterectomies performed each year in the
United States are done through a laparotomy.4 The
overall rate of surgical site infection after abdominal
hysterectomy has been reported to be approximately
4–6%.5,6 Furthermore, surgical site infections are
responsible for one third of the readmissions after
hysterectomy.3 Therefore, reduction in surgical site
infections after abdominal hysterectomy has become
one of the Centers for Medicare & Medicaid Services’
OBSTETRICS & GYNECOLOGY 319
targets for quality improvement.7 However, the exist-
ing published guidelines for interventions to prevent
infections do not routinely specify the choice of
antiseptic for skin preparation before abdominal
hysterectomy.8,9
Chlorhexidine-alcohol topical antiseptics have
been shown to outperform povidone-iodine in pre-
venting surgical site infections related to vascular
catheter site insertion.10,11 A recent randomized
controlled trial comparing the use of povidone-
iodine compared with chlorhexidine-alcohol in adults
undergoing open surgery found a significantly lower
surgical site infection rate in the chlorhexidine-alcohol
group (9.5% compared with 16.1%, P5.004).12 How-
ever, the generalizability of this trial in gynecologic
surgery is limited because only 10% of the patient
population in this trial had undergone hysterectomy.
Therefore, we undertook this study to compare
preoperative chlorhexidine-alcohol topical antiseptic
agent with povidone-iodine in patients undergoing
abdominal hysterectomy for benign indications.
MATERIALS AND METHODS
A retrospective cohort study of patients undergoing
abdominal hysterectomy from July 2012 to February
2015 in the Michigan Surgical Quality Collaborative
(referred to as “the collaborative”) was performed.
The collaborative is a Blue Cross and Blue Shield of
Michigan-Blue Care Network-funded database volun-
tarily populated by both academic and community
hospitals throughout the state. It includes patients
from all insurance payers. At participating hospitals,
trained, dedicated nurse abstractors collect patient
characteristics, intraoperative processes of care, and
30-day postoperative outcomes from general and
vascular surgery and hysterectomy cases. Nurse
abstractors use chart reviews, patient phone calls,
and occasionally discussion with physicians to ensure
complete capture of data regardless of the hospital
where subsequent treatments happen. Detailed
methods of the registry’s data collection have been
described previously.13
Women 18 years of age or older undergoing
abdominal hysterectomy for a benign indication were
included in the study. Patients were excluded if data
were missing for preoperative antibiotic administra-
tion, skin antiseptic preparation agent information, or
postoperative surgical site infection data. Because the
focus of this study was routine hysterectomy, we
excluded small patient subgroups with a much higher
baseline risk of surgical site infection and those with
an existing infection before surgery. Specifically,
patients with a diagnosis of an open wound or
320 Uppal et al Chlorhexidine-Alcohol Use in Hysterectomy
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preoperative sepsis as well as those with wound
classification categories defined as dirty or contami-
nated were excluded. Surgeries labeled as emergent
operations were also excluded, because this category
does not reflect routine abdominal hysterectomy.
Patients on chronic steroids were excluded as a result
of concerns of immunosuppression. Lastly, patients
who did not receive preoperative antibiotics based on
the criteria set forth by the American College of
Obstetricians and Gynecologists14 and the Surgical
Care Improvement Project were excluded. A detailed
overview of the cohort development is provided in
Figure 1. Michigan Surgical Quality Collaborative
data sets provided to the researchers contain no
patient, hospital, or health care provider identifier.
Therefore, this study met the criteria for “exempt”
status by the University of Michigan institutional
review board–medical (HUM00073978).
The following demographic data, medical comor-
bidities, and perioperative data were abstracted: age,
body mass index (BMI, calculated as weight (kg)/
[height (m)]2), race (categorized as either white or
nonwhite), insurance status (Medicare, Medicaid,
private, uninsured, missing, or other), functional status
(a patient’s ability to perform basic daily activities to
maintain their health, measured as being either depen-
dent or independent), American Society of Anesthesi-
ologists (ASA) classification score (dichotomized to
American Association of Anesthesiology class less
than 3 or 3 or greater), diabetes mellitus (defined as
requiring oral hypoglycemic agents or insulin),
tobacco use (defined as smoking cigarettes, cigars, or
a pipe, chewed tobacco, or used marijuana within the
Fig. 1. Details of the cohort development.
Uppal. Chlorohexidine-Alcohol Use in Hysterectomy. Obstet Gy-
necol 2017.
OBSTETRICS & GYNECOLOGY
past year), alcohol use (defined as greater than two
drinks in the 2 weeks before admission), estimated
blood loss (in milliliters), operative time
(in minutes), intraoperative adhesions (categorized as
none, minor [requiring lysis of adhesions less than
45 minutes], and major [requiring lysis of adhesions
45 minutes or greater]), and bowel surgery performed
(yes or no). Prophylactic antibiotics were categorized
as b-lactam antibiotics or b-lactam alternatives. This
categorization was done based on the findings of our
previous study from this database, which showed
increased odds of surgical site infection with b-lactam
alternative antibiotics in hysterectomy.15
We hypothesized that the use of chlorhexidine-
alcohol topical antiseptic is associated with a lower
likelihood of developing surgical site infection. There-
fore, the primary outcome measure of this study was
the occurrence of any surgical site infection (superfi-
cial and deep or organ space) within 30 days of
surgery, as defined by the Centers for Disease Control
and Prevention.16
Descriptive analyses of demographics, comor-
bidities, perioperative data, and postoperative
surgical site infection were performed. Univariate
analyses were performed to identify factors signifi-
cantly associated with developing postoperative
surgical site infection. x2 and Fisher exact tests were
used for categorical variables and parametric one-
way analysis of variance or nonparametric
Wilcoxon–Mann–Whitney tests were used for
continuous variables wherever appropriate. Factors
associated with development of surgical site
infections based on previous research or clinical
plausibility were included in multivariable analyses
to ascertain the independent association of skin
preparation agent with the rate of surgical site
infection.15 These factors included: patient demo-
graphic factors (age and BMI), medical comorbidities
(ASA class and diabetes status), perioperative
variables (estimated blood loss, surgical time,
intraoperative adhesions, and antibiotic categories),
and hospital characteristics (bed size and teaching
status). A second model was constructed using
backward stepwise regression of variables with P,.2
as elimination criteria to verify the results of the first
model. To account for clustering of data at the
hospital level, we used Huber–Eicker–White robust
standard errors, which strengthen our model by
controlling for variation between hospital sites.17–19
Propensity score matching was used to further
validate the results of logistic regression modeling.
For this analysis, we performed one-to-one matching
using calipers of 0.001.
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Stata 14.0 SE for MacIntosh was used for all
analyses.
RESULTS
Of the total 4,259 abdominal hysterectomies included,
chlorhexidine-alcohol was used in 70.5% (n53,005)
and povidone-iodine in 29.5% (n51,254) of surgeries.
The overall unadjusted rate of any surgical site
infection was 2.9% (95% CI 2.5–3.5; n5124). The
unadjusted rate of surgical site infection 2.6% (95%
CI 2.1–3.3; n579) for chlorhexidine-alcohol and
3.6% (95% CI 2.7–4.8; n545; P5.09) for the
povidone-iodine group.
Univariate analysis of the demographic factors,
medical comorbidities, perioperative variables, intra-
operative variables, and hospital factors associated
with the development of surgical site infection is
presented in Table 1. The baseline comparison
between the patients in the povidone-iodine group
and those in the chlorhexidine-alcohol group is
presented in Table 2. The chlorhexidine-alcohol
group had a higher proportion of patients with several
factors associated with surgical site infection develop-
ment (Table 2). For example, patients receiving
chlorhexidine-alcohol were more likely to be older,
nonwhite, have a higher BMI and a higher proportion
of patients with ASA class 3 or greater, be functionally
dependent, higher mean blood loss, and increased
mean surgical time, higher proportion of patients with
intraoperative adhesions categorized as major, and
required bowel surgery. The unadjusted rate of
surgical site infection for patients treated with
chlorhexidine-alcohol was 2.6% (95% CI 2.1–3.3;
n579) and povidone-iodine was 3.6% (95% CI 2.7–
4.8; n545; P5.09; Table 3).
After adjusting for differences between popula-
tions using multivariate logistic regression models, we
estimate that patients receiving chlorhexidine-alcohol
had 44% lower odds of developing a surgical site
infection (adjusted odds ratio [OR] 0.56, 95% CI
0.37–0.84, P5.01) in the first model using clinically
plausible variables (Table 4). The area under the
curve for this model was estimated to be 0.696. In
the second model, using backward stepwise approach,
patients receiving chlorhexidine-alcohol had 35%
lower odds of developing a surgical site infection
(adjusted OR 0.65, 95% CI 0.45–0.93, P5.02).
However, this model had a lower area under the curve
of 0.66.
Propensity score matching (one to one) yielded
845 patients receiving povidone-iodine skin prepara-
tion agent and 808 patients in the chlorhexidine-
alcohol group. Propensity-matched cohorts were
Chlorhexidine-Alcohol Use in Hysterectomy 321
Table 1. Predictors of Surgical Site Infection (Unadjusted)

Any Surgical Site Infection

Variable No (n54,135) Yes (n5124) P

Demographics
Age (y) 47.09610.11 47.5169.82 .648
Race
White or Caucasian 2,590 (97.2) 74 (2.8) .502
Nonwhite 1,545 (96.9) 50 (3.1)
BMI (kg/m2) 31.3768.64 34.6468.64 ,.001
Insurance status
Private 2,796 (97.3) 78 (2.7) .214
Medicare 406 (97.8) 9 (2.2)
Medicaid 653 (95.9) 28 (4.1)
Uninsured 73 (98.6) 1 (1.4)
Missing or other 207 (96.3) 8 (3.7)
Medical comorbidities
ASA class
Less than 3 25 (96.2) 1 (3.9) .040
3 or greater 4,110 (97.1) 123 (2.9)
Functional status
Dependent 3,791 (97.2) 110 (2.8) .776
Independent 344 (96.1) 14 (3.9)
Diabetes present
No 3,039 (97.3) 86 (2.8) .24
Yes 1,096 (96.7) 38 (3.4)
Tobacco use in past year
No 3,039 (97.3) 86 (2.8) .304
Yes 1,096 (96.7) 38 (3.4)
Alcohol use in the past year
No 4,092 (97.1) 122 (2.9)
Yes 43 (95.6) 2 (4.4)
Perioperative variables
Skin antiseptic choice
Chlorhexidine-alcohol 2,926 (97.4) 79 (2.6) .090
Povidone-iodine 1,209 (96.4) 45 (3.6)
Preoperative antibiotic
b-lactam 3,458 (97.3) 97 (2.8) .115
b-lactam alternative 677 (96.2) 27 (3.8)
Intraoperative variables
Estimated blood loss (mL) 317.946339.66 349.606369.93 .308
Surgical time (min) 124.95659.86 137.91675.67 .019
Intraoperative adhesions
None 2,935 (97.5) 76 (2.5) .002
Minor 494 (97.6) 12 (2.4)
Major 706 (95.2) 36 (4.8)
Bowel surgery
No 4,090 (97.2) 118 (2.8) ,.001
Yes 45 (88.2) 6 (11.8)
Hospital characteristics
Bed size
Less than 300 beds 1,224 (96.9) 39 (3.1) .387
300–499 beds 1,848 (97.1) 55 (2.9)
Greater than 500 beds 954 (97.6) 24 (2.4)
Unknown 109 (94.8) 6 (5.2)
Teaching status
Community hospital 1,602 (97.3) 44 (2.7) .284
Academic hospital 2,424 (97) 74 (3)
Unknown 109 (94.8) 6 (5.2)
BMI, body mass index; ASA, American Society of Anesthesiologists.
Data are mean6SD or n (%) unless otherwise specified.

322 Uppal et al Chlorhexidine-Alcohol Use in Hysterectomy OBSTETRICS & GYNECOLOGY

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Table 2. Skin Antiseptic Types Used in Patients Undergoing Hysterectomy and Surgical Site Infection
(Entire Cohort and Propensity-Matched Cohort)

Unmatched Cohort Propensity Score-Matched Cohort

Chlorhexidine- Povidone- Chlorhexidine- Povidone-
Alcohol Iodine Alcohol Iodine
Variable (n53,005) (n51,254) P (n5808) (n5845) P

Demographics
Age (y) 46.7469.45 47.96611.46 ,.001 47.1469.83 46.85610.38 .554
Nonwhite race 1,267 (42.2) 328 (26.2) ,.001 258 (32) 279 (33) .637
BMI (kg/m2) 31.8168.08 30.6669.87 ,.001 30.9767.56 30.85610.90 .800
Insurance status
Medicare 259 (8.6) 156 (12.44) .003 76 (9) 76 (9) .888
Medicaid 483 (16.1) 198 (15.8) 131 (16) 134 (16)
Private 2,050 (68.2) 824 (65.7) 548 (68) 574 (68)
Uninsured 52 (1.7) 22 (1.8) 11 (1) 17 (2)
Missing or other 161 (5.4) 54 (4.3) 42 (5) 44 (5)
Medical comorbidities
ASA class 3 or greater 742 (24.7) 238 (19.0) ,.001 169 (21) 161 (19) .344
Functional status dependent 25 (0.8) 1 (0.1) .004 3 (0) 1 (0) .295
Diabetes present 251 (8.4) 107 (8.5) .847 63 (8) 70 (8) .716
Tobacco use in past year 780 (26.0) 354 (28.2) .126 218 (27) 228 (27) .999
Alcohol use in the past year 33 (1.1) 12 (1.0) .681 10 (1) 11 (1) .907
Perioperative variables
Preoperative antibiotics
b-lactam alternatives 522 (17.4) 182 (14.5) 103 (13) 93 (11) .548
Intraoperative variables
Estimated blood loss (mL) 348.726360.96 247.316273.02 ,.001 285.256299.78 272.456306.73 .391
Surgical time (min) 131.03661.19 111.65656.21 ,.001 118.14651.30 116.84660.81 .640
Intraoperative adhesions
None 2,038 (67.8) 973 (77.6) ,.001 285.25 (299.78) 272.45 (306.73) .859
Minor 382 (12.7) 124 (9.9) 285.25 (299.78) 272.45 (306.73)
Major 585 (19.5) 157 (12.5) 285.25 (299.78) 272.45 (306.73)
Bowel surgery
Yes 46 (1.5) 5 (0.4) .002 7 (1) 5 (1) .511
Hospital characteristics
Bed size
Less than 300 beds 858 (28.6) 405 (32.3) ,.001 248 (31) 283 (33) .464
300–499 beds 1,314 (43.7) 589 (47) 379 (47) 384 (45)
Greater than 500 beds 757 (25.2) 221 (17.6) 181 (22) 178 (21)
Unknown 76 (2.5) 6 (3.1) 0 0
Teaching status
Community hospital 921 (30.7) 725 (57.8) ,.001 426 (53) 429 (51) .427
Academic hospital 2,008 (66.8) 490 (39.2) 382 (47) 416 (49)
Unknown 76 (2.5) 39 (3.1) 0 0
BMI, body mass index; ASA, American Society of Anesthesiologists.
Data are mean6SD or n (%) unless otherwise specified.

similar with none of the factors significantly different
between the two groups (Table 2). The rate of surgi-
cal site infection in the matched cohort was 1.5%
(95% CI 0.8–2.6; n512) for the chlorhexidine-
alcohol group and 4.7% (95% CI 3.5–6.4; n540;
propensity matched cohort OR 0.31, 95% CI 0.17–
5.6, P,.001; Table 3).
Figure 2 highlights the increase in surgical site
infection as a function of proportion of hysterectomies
using povidone-iodine skin preparation at each
hospital site. Hospitals with a higher rate of
povidone-iodine use had higher rates of surgical site
infection.
DISCUSSION
In patients undergoing abdominal hysterectomy in
a statewide collaborative, preoperative skin prepara-
tion with chlorhexidine-alcohol is associated with
lower odds of developing surgical site infection
compared with povidone-iodine (adjusted OR 0.56).
This finding is important for several reasons. Abdom-
inal hysterectomy remains common in the United

VOL. 130, NO. 2, AUGUST 2017 Uppal et al Chlorhexidine-Alcohol Use in Hysterectomy 323

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Table 3. Surgical Site Infection (Any): Unmatched and Propensity Score-Matched Cohorts
Unmatched Cohort
Primary Chlorhexidine-Alcohol Povidone-Iodine
Outcome (n53,005) (n51,254)
Surgical site
infection
(any)
No 2,926 (97.4) 1,209 (96.4)
Yes 79 (2.6) 45 (3.6)
Data are n (%) unless otherwise specified.
States with 200,000 open abdominal hysterectomies
performed per year. Therefore, evidence-based inter-
ventions to reduce surgical site infections are urgently
needed. Second, surgical site infections after abdom-
inal hysterectomy will be a metric included in the
Hospital Acquired Condition Reduction Program
score, which will affect hospital reimbursements.20
Third, surgical site infections are the single most sig-
nificant cause for readmissions after hysterectomy.3
Finally, surgical site infections have been shown to
be associated with a significant increase in morbidity
and mortality after surgery as well as a negatively
effect on patient quality of life of patients.21 Although
major perioperative guidelines specify the choice of
antibiotics to prevent infections, to our knowledge,
there are no current established national guidelines
that indicate the choice of preoperative topical skin
antisepsis before abdominal hysterectomy. Our find-
ings, along with the previous randomized controlled
trials in the field of general surgery, provide a basis for
recommending chlorhexidine-alcohol for abdominal
hysterectomy.12
Our results are consistent with previous studies
comparing povidone-iodine with chlorhexidine-
alcohol. Levin et al22 reported on a study comparing
chlorhexidine-alcohol with povidone-iodine in gyne-
cologic surgeries. Overall reduction in surgical site
infections with the implementation of chlorhexidine-
alcohol (from 14.6% to 4.5%) was noted in this study.
Although the baseline rates of surgical site infections
were much higher than previously reported rates in
the United States, this study supported the use of
chlorhexidine-alcohol instead of povidone-iodine.
Darouiche et al12 reported the results of their random-
ized controlled trial and concluded that
chlorhexidine-alcohol was superior to povidone-
iodine in preventing surgical site infections (rate of
16% compared with 9.5%, P5.004, respectively) in
clean-contaminated surgeries. However, their study
included only 40 gynecologic patients in each arm;
given the overall low rate of surgical site infection
324 Uppal et al Chlorhexidine-Alcohol Use in Hysterectomy
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Propensity Score-Matched Cohort
Chlorhexidine- Povidone-Iodine
P Alcohol (n5808) (n5845) P
0.09 796 (98.5) 805 (95.3) ,.001
12 (1.5) 40 (4.7)
after hysterectomy (compared with other procedures
like bowel surgery), these results needed further inves-
tigation in patients undergoing hysterectomy.
Similarly, a comprehensive systematic review found
an overall risk reduction of 32% with the use of
chlorhexidine-alcohol compared with povidone-
iodine in clean-contaminated surgery.23
The mechanism of action and the superiority of
chlorhexidine-alcohol seem to be related to its
persistent activity with rapid onset of action related
to drying of alcohol and the ability of chlorhexidine
to remain active even when the field is soiled with
blood or serum.24 However, it is unclear whether the
superiority of chlorhexidine-alcohol is the result of
the alcohol base or the chlorhexidine component
itself. In cesarean deliveries, Tuuli et al25 reported
that the use of chlorhexidine-alcohol for preopera-
tive skin antisepsis resulted in a significantly lower
risk of surgical site infections when compared with
iodine in alcohol, indicating that chlorhexidine
gluconate may help decreases the rate of surgical site
infection. Further studies comparing alcohol-based
preparations are needed to answer this question,
albeit a randomized study may not be feasible as
a result of the necessity of a relatively large sample
size.
The alcohol-based skin preparations have their
limitations. Before evaporation, a significant fire risk
exists and significant injuries to the patient and staff
have been reported.26,27 In addition, these agents
cannot be used on mucosal surfaces. Therefore, aque-
ous preparations have a role in vaginal hysterectomy
as well as in vaginal preparation during abdominal
hysterectomy. Although the isopropyl alcohol and
chlorhexidine gluconate pose a very small risk of
combustion at temperatures provided by the electro-
surgical devices, the overall qualitative benefits from
a reduction of surgical site infections in the
chlorhexidine-alcohol group make this agent a supe-
rior choice. Strategies to ensure adequate waiting time
after skin preparation during timeout to prevent
OBSTETRICS & GYNECOLOGY
Table 4. Logistic Regression Model: Independent Predictors of Surgical Site Infection

Model 1 (All Factors Included Based Model 2 (Backward Stepwise

on Clinically Plausible Variables) Approach)
Variable Unadjusted OR Adjusted OR 95% CI P Adjusted OR 95% CI P

Demographics
Age (per year) 1.004 1.015 0.987–1.044 .29 X X X
BMI (per 1 kg/m2) 1.02 1.017 0.999–1.036 .06 1.02 1.002–1.045 .04
Insurance status
Private Ref Ref Ref Ref Ref Ref Ref
Medicare 0.569 0.227–1.425 .23 0.72 0.31–1.64 .43
Medicaid 1.467 0.946–2.275 .09 1.47 0.97–2.2 .07
Uninsured 0.546 0.085–3.51 .52 0.55 0.08–3.7 .54
Missing or other 1.398 0.769–2.542 .27 1.4 0.79–2.47 .24
Medical comorbidities
ASA class
Less than 3 Ref Ref Ref Ref X X X
3 or greater 1.5 1.243 0.86–1.797 .25 X X X
Functional status
Dependent NI NI NI NI X X X
Independent NI NI NI X X X
Diabetes status
No Ref Ref Ref Ref X X X
Yes 1.4 0.941 0.489–1.809 .86 X X X
Tobacco use in past year
No NI NI NI NI X X X
Yes NI NI NI NI X X X
Alcohol use in past year
No NI NI NI NI X X X
Yes NI NI NI NI X X X
Perioperative variables
Skin antiseptic choice
Povidone-iodine Ref Ref Ref Ref Ref Ref Ref
Chlorhexidine-alcohol 0.73 0.557 0.37–0.839 .01 0.65 0.45–0.93 .02
Preoperative antibiotics
b-lactam Ref Ref Ref Ref Ref Ref Ref
b-lactam alternative 1.81 1.777 1.144–2.761 .01 1.77 1.16–2.7 .007
Intraoperative variables
Estimated blood loss (per mL) 1 0.999–1.001 .94 X X X
Surgical time (per min) 1.001 0.998–1.005 .48 X X X
Intraoperative adhesions
None Ref Ref Ref Ref Ref Ref Ref
Minor 0.923 0.512–1.663 .79 0.84 0.45–1.56 .59
Major 1.942 1.274–2.959 ,.001 1.83 1.24–2.7 .002
Bowel surgery
No Ref Ref Ref Ref Ref Ref Ref
Yes 4.031 1.414–11.493 .01 4.76 1.7–13.4 .003
Hospital characteristics
Teaching status
Community hospital Ref Ref Ref Ref X X X
Academic hospital 1.11 1.343 0.766–2.353 .3 X X X
Bed size
Less than 300 beds Ref Ref Ref Ref X X X
300–499 beds 0.93 0.822 0.482–1.403 .47 X X X
Greater than 500 beds 0.79 0.656 0.335–1.283 .22 X X X
OR, odds ratio; BMI, body mass index; Ref, referent; ASA, American Society of Anesthesiologists; NI, variable not included in model 1.
X indicates the variable was removed in the backward stepwise regression (cutoff for removal was P..2).

surgical fires are recommended.28,29 Allergies to chlorhexidine-alcohol allergy remain unknown, one
chlorhexidine-alcohol have been reported in the study estimated that skin patch testing revealed
literature. Although the precise estimates of positive reactions in 2% of the patients tested. Further

VOL. 130, NO. 2, AUGUST 2017 Uppal et al Chlorhexidine-Alcohol Use in Hysterectomy 325

Copyright ª by The American College of Obstetricians

and Gynecologists. Published by Wolters Kluwer Health, Inc.
Unauthorized reproduction of this article is prohibited.

Fig. 2. Rates of surgical site infection by the hospital’s
proportion of cases using povidone-iodine topical antisep-
tic before abdominal hysterectomy. Size of the bubble is
proportionate to the number of cases contributed by that
hospital. Red line indicates fitted values.
Uppal. Chlorohexidine-Alcohol Use in Hysterectomy. Obstet
Gynecol 2017.
studies should make note of both severe allergies as
well as skin reactions in patients in the chlorhexidine-
alcohol group.30
This study has many notable strengths. The
collaborative is a collective of Michigan hospitals
throughout the state with a common goal of surgical
quality improvement through improved patient care
and reduction of health care costs. The collaborative
focuses on standardized data collection and nurse
abstractors who attend regular seminars and are
audited frequently. Although other data sets are
retrieved from billing and administrative data that
does not include postdischarge data or standardized
definitions, the collaborative uses the Centers for
Disease Control and Prevention definition of surgical
site infections and uses a 30-day endpoint to capture
any complications for both inpatient and outpatient
procedures. Lastly, we used a multivariate logistic
regression model to account for multiple patient and
perioperative factors such as type of prophylactic
antibiotic and estimated blood loss. These factors
are known predictors of surgical site infections and
are not readily available in administrative data sets.31
Limitations in our study include the lack of data
on agents used during the preparation of the vagina
for hysterectomy. Variation in the use of povidone-
iodine, saline solution, or 2% chlorhexidine vaginal
preparation could affect the conclusion of our study.
In addition, there could be several factors such as
level of operator experience, variation in surgical
technique, and the presence of a trainee that can
affect the incidence of surgical site infections. Lastly,
because this is a retrospective evaluation, there is
326 Uppal et al Chlorhexidine-Alcohol Use in Hysterectomy
Copyright ª by The American College of Obstetricians
and Gynecologists. Published by Wolters Kluwer Health, Inc.
Unauthorized reproduction of this article is prohibited.
a potential of remaining bias as a result of unmeasured
confounders.
The choice of preoperative skin antiseptic given
before abdominal hysterectomy is an important factor
in development of surgical site infections.
Chlorhexidine-alcohol skin antiseptic resulted in an
overall decreased likelihood of surgical site infections
compared with povidone-iodine when adjusted for
patient and perioperative factors. Given an overall
low rate of surgical site infection after hysterectomy,
conducting a clinical trial will require a very large
sample size and may be prohibitively expensive.
Findings from this retrospective study of patients
undergoing abdominal hysterectomy along with
randomized controlled trial data from the general
surgery literature should prompt the development of
guidelines to focus on specifying the chlorhexidine-
alcohol-based skin antiseptic before abdominal
surgery.
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